thrombolytic therqapy in stroke 14.2.01
TRANSCRIPT
Thrombolytic Therapy of Thrombolytic Therapy of Acute Ischemic strokeAcute Ischemic stroke
Dr Parth Sarthi DebDr Parth Sarthi Deb
Dr Srikant JawalkarDr Srikant Jawalkar
Apollo Hospital HyderabadApollo Hospital Hyderabad
BackgroundBackground
Neuro-protection and anti-thrombotic Neuro-protection and anti-thrombotic
treatment have not changed the treatment have not changed the
outcome of stroke outcome of stroke
Only effective way to protect ischemic Only effective way to protect ischemic
neurons is re-vascularization in timeneurons is re-vascularization in time
FactsFacts
The ischemia threshold for The ischemia threshold for neuronal death will never changeneuronal death will never change
Mode of re-vascularization can be Mode of re-vascularization can be Mechanical or PharmacologicalMechanical or Pharmacological
Most effective and practical way to Most effective and practical way to achieve this is still awaitedachieve this is still awaited
What shall we do ?What shall we do ?
1. 1. WaitWait till the result of double blind till the result of double blind placebo controlled multicentric trial of placebo controlled multicentric trial of ideal re-vascularization is outideal re-vascularization is out
2. 2. Satisfied Satisfied with neuro-protection and with neuro-protection and anti-thrombotic measuresanti-thrombotic measures
3. 3. TryTry thrombolysis with caution when thrombolysis with caution when ever suitableever suitable
PatientsPatients
Period: Period: 1992-1992-0000 Total ischemic strokesTotal ischemic strokes 801801 Thrombolysis done Thrombolysis done 3636 Male Male 2929 FemalesFemales 77 Age in yearsAge in years 20-8020-80
Inclusion CriteriaInclusion Criteria
A.A. Clinical evidence for an Clinical evidence for an ischemic strokeischemic stroke
B. Normal CT ScanB. Normal CT Scan
C.C. Age >18 yearsAge >18 years
D.D. Onset of stroke Ant cir Onset of stroke Ant cir 6 hr6 hr
Post cir Post cir 12 hr12 hr
E.E. Normal BT, CT, PT, PTT and Normal BT, CT, PT, PTT and platelet platelet
Exclusion CriteriaExclusion Criteria
A. A. Stroke or serious head trauma in past 3 Stroke or serious head trauma in past 3 monthsmonths
B.B. Major surgery or invasive procedure Major surgery or invasive procedure within past 14 dayswithin past 14 days
C.C. GI or urinary bleeding within past GI or urinary bleeding within past 21 days21 days
D.D. Puncture of noncompressible artery Puncture of noncompressible artery or biopsy of internal organ within past 7 or biopsy of internal organ within past 7 daysdays
E.E. Ongoing alcohol or drug abuseOngoing alcohol or drug abuse
Exclusion Criteria cont..Exclusion Criteria cont..
F.F. Seizure preceding or during strokeSeizure preceding or during stroke
G.G. History of intracranial hemorrhage History of intracranial hemorrhage (including subarachnoid bleeds) or (including subarachnoid bleeds) or known history of cerebral vascular known history of cerebral vascular malformations (including aneurysms or malformations (including aneurysms or arteriovenous malformations)arteriovenous malformations)
H.H. Pericarditis, endocarditis, septic Pericarditis, endocarditis, septic emboli, recent pregnancy, or active emboli, recent pregnancy, or active inflammatory bowel diseaseinflammatory bowel disease
Thrombolysis in acute Thrombolysis in acute strokestroke
Within 3 hour of Stroke Small Vessel
Medium Vessel
IV rTPA/URK
Large Vessel
IA rTPA/URK
Stop
Thrombolytic AgentsThrombolytic Agents
Streptokinase: Streptokinase: IA IA 1-1.5 lakh units1-1.5 lakh units
IV IV 2.5-10 lakh units2.5-10 lakh units
Urokinase:Urokinase: IV IV 5-10 lakh units5-10 lakh units
IA 5-10 lakh unitsIA 5-10 lakh units
rTPA:rTPA: IAIA 10-40 mg10-40 mg
IVIV 40-50 mg40-50 mg
Route of AdministrationRoute of Administration
DrugDrug IVIV IAIA TotalTotal
STKSTK 77 22 99
URKURK 1515 66 2121
rTPArTPA 44 22 66
TotalTotal 2626 1010 3636
End Point of TreatmentEnd Point of Treatment
Total calculated dose givenTotal calculated dose given
Patient showed significant improvementPatient showed significant improvement
Significant bleeding complicationSignificant bleeding complication
Severe allergic reactionSevere allergic reaction
AgeAge MaleMale FemaleFemale TotalTotal
20-3920-39 55 -- 55
40-5940-59 1212 55 1717
60-8060-80 1212 22 1414
TotalTotal 2929 77 3636
Age Sex DistributionAge Sex Distribution
Arterial Territory and SeverityArterial Territory and Severity
ArteryArtery ConsciousConscious UnconsciouUnconsciouss
TotalTotal
ACAACA 1616 1111 2727
PCAPCA 22 77 99
TotalTotal 1818 1818 3636
Outcome and Agent usedOutcome and Agent used
RecoveryRecovery STKSTK URKURK rTPArTPA TotalTotal
IndependenIndependentt
44 1313 22 1919
DependentDependent 22 44 11 77
DeathDeath 33 44 33 1010
TotalTotal 99 2121 66 3636
Outcome and Arterial TerritoryOutcome and Arterial Territory
RecoverRecoveryy
ACAACA PCAPCA TotalTotal
ConCon UncUnc ConCon UncUnc
IndInd 1212 11 22 44 1919
DepDep 33 33 -- 11 77
DeathDeath 11 77 -- 22 1010
TotalTotal 1616 1111 22 77 3636
Outcome and Timing of TreatmentOutcome and Timing of Treatment
OutcomOutcomee
<1<1hh
1-3h1-3h 3-6h3-6h TotalTotal
IndInd 66 44 99 1919
DepDep -- 11 66 77
DeathDeath 33 11 66 1010
TotalTotal 99 66 2121 3636
Outcome and CT scanOutcome and CT scan
OutcomeOutcome NormaNormall
EarlyEarly TotalTotal
IndependentIndependent 1515 11 1616
DependentDependent 55 22 77
DeathDeath 77 33 1010
TotalTotal 2626 66 3333
Complication of therapyComplication of therapy
ComplicationComplication STKSTK URKURK rTPArTPA TotalTotal
Skin RashSkin Rash -- 11 -- 11
BronchospasmBronchospasm -- 11 11 22
AnaphylaxisAnaphylaxis -- 11 22 33
Gum bleedGum bleed -- 11 11 22
Gastric bleedGastric bleed 22 11 -- 33
Urinary bleedUrinary bleed -- 11 -- 11
IC bleedIC bleed -- 11 -- 11
Hem transHem trans 11 -- -- 11
Toxic edemaToxic edema 22 55 22 88
IC spasmIC spasm -- 11 -- 11
ConclusionConclusion
Outcome was not related to the Drug usedOutcome was not related to the Drug used Ant circulation minor stroke and posterior Ant circulation minor stroke and posterior
circulation stroke has better prognosiscirculation stroke has better prognosis Ant. circulation major stroke did well on IA Ant. circulation major stroke did well on IA
thrombolysis.thrombolysis. Normal CT before treatment was not Normal CT before treatment was not
related to good outcome. But abnormal CT related to good outcome. But abnormal CT has poor outcome.has poor outcome.
Hemorrhagic complication are dose related.Hemorrhagic complication are dose related.
Thank YouThank You